[Congressional Record Volume 152, Number 135 (Friday, December 8, 2006)]
[Senate]
[Pages S11647-S11658]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
[[Page S11647]]
Senate
NATIONAL INSTITUTES OF HEALTH REFORM ACT OF 2006
Mr. FRIST. Mr. President, I ask unanimous consent that the Committee
on Health, Education, Labor and Pensions be discharged from further
consideration of H.R. 6164, and the Senate proceed to its immediate
consideration.
The PRESIDING OFFICER. Without objection, it is so ordered. The clerk
will report the bill by title.
The legislative clerk read as follows:
A bill (H.R. 6164) to amend title IV of the Public Health
Service Act to revise and extend the authorities of the
National Institutes of Health, and for other purposes.
There being no objection, the Senate proceeded to consider the bill.
enrollment periods
Mr. GRASSLEY. I wish to engage my colleague Senator Baucus in a
colloquy concerning the Tax Relief and Health Care Act of 2006. This
bill contains a
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TRENT LOTT, Chairman.
[[Page S11648]]
provision that would allow certain Medicare Advantage plans to enroll
individuals at any time during the year. I am concerned about this
provision for two reasons: No. 1, the effect it will have on the
Medicare Advantage program, and No. 2, the process by which it was
included in this package.
Mr. BAUCUS. I thank you for bringing this provision up for
discussion. I have concerns as well.
Mr. GRASSLEY. Under current law, beneficiaries can decide to stay in
the traditional fee-for-service program or enroll in Medicare Advantage
plans during the annual open period, which lasts from November 15 to
December 31. They can also make certain changes one time between
January and March of the following year. I remember how much time and
effort we spent designing these enrollment policies when we worked
together on the Medicare Modernization Act of 2003. Wouldn't you agree
this provision is a significant policy change?
Mr. BAUCUS. That is an understatement. This provision would allow
some but not all types of Medicare Advantage plans to enroll
individuals throughout the year. Only those plans that do not offer
prescription drug coverage will be given this special treatment. This
may sound like a small change because it only affects a certain type of
Medicare Advantage plan. But it creates an unlevel playing field
between plans with no drug coverage and Medicare Advantage plans that
have decided to offer prescription drug coverage.
Mr. GRASSLEY. That is exactly my concern, too. I am also disappointed
in the process that led to the provision being included in the final
bill. We had an understanding that we would only include agreed-upon
extensions and must-do health items in the package and not make major
policy decisions that had not gone through the regular process. This
provision does not meet that standard.
Mr. BAUCUS. No, it does not. In fact, I soundly rejected the proposal
during the negotiations with our House colleagues. They were clearly
informed of my position on the matter. Our final agreement did not
include this provision.
Mr. GRASSLEY. It disturbs me, that this major policy change--one that
treats some plans unfairly--was included at last minute by the House
rules committee. I do not operate like that, and I know you do not,
either. Unfortunately, we are stuck with this provision for the time
being. But I assure of my commitment to working with you as soon as
possible next year to revisit this provision.
Mr. BAUCUS. I thank my colleague and good friend from Iowa. I look
forward to working with you next year on this and all of the business
we will have before our committee.
children's health insurance program
Mr. ROCKEFELLER. Chairman Grassley and Ranking Member Baucus, I would
like to begin by thanking you for your efforts to address the impending
Children's Health Insurance Program, CHIP, shortfalls as part of this
end-of-the-year package. As many as 17 States face the prospect of not
having enough Federal CHIP dollars to cover the children currently
enrolled in their programs. Estimates by the Congressional Research
Service and others indicate that these shortfalls will total
approximately $920 million next year and could put the health care
coverage of as many as 630,000 children in jeopardy. This compromise,
struck between you, Congressman Barton, and Congressman Dingell, while
not 100 percent of what everybody wanted, takes a significant step
toward addressing that problem.
Mr. GRASSLEY. Thank you, Senator Rockefeller. We share an interest in
making sure that States have adequate Federal funding to cover children
through CHIP. No one wants to see children lose coverage, and we hope
the provisions in this bill will help States on a temporary basis until
we have time to work out a more permanent solution to the CHIP
financing structure. Now I know that there are a lot of concerns about
this package. And I want to make it clear that Senator Baucus and I
thought this was what we could pass right now. We are hopeful that we
can pass this package here in the Senate and then get House agreement
tonight or tomorrow so that we can forestall these shortfalls for the
first part of the year.
I want to make it clear, however, that nothing in this package binds
us for CHIP reauthorization next year. There is discomfort with the
CHIP provisions on both sides of the aisle. But Senators are willing to
compromise in order to get something done for children before we go
home. Therefore, we should put aside our differences and individual
gripes in order to get something productive passed.
Mr. BAUCUS. I want to associate myself with the remarks of the
chairman. This bill is so important, so vital to the lives of hundreds
of thousands of children who need health coverage. I am so proud that
the Senate and the House were able to get together and work out a deal
to get this done this year. I was disappointed we weren't able to
include this in the tax extenders package that Senator Grassley and I
worked on, so it is very gratifying to know we were able to do this. I
want to especially thank Chairman Grassley and his staff, Becky Shipp,
for their dedication to this effort and commitment to the program. I
would also like to thank Chairman Barton and his staff, Ryan Long, for
their willingness to help in this process, and Congressman Dingell and
his staff, Bridgett Taylor and Amy Hall, for their dogged determination
to get this done. I also agree with Chairman Grassley in his view that
the CHIP provisions in this bill will not set a precedent for
reauthorization next year. Instead, this is a temporary fix--a
downpayment toward addressing a long-term problem of increasing demand
for CHIP and not enough Federal funds to go around. In an ideal world,
Senator Grassley and I would have liked to put new money on the table
to fully fund the shortfalls. However, we are operating under
significant budget constraints. This package represents what we think
we can do now, despite those constraints. We know we will need to
revisit this issue next year, either as part of the reauthorization of
the CHIP program, or apart from that, to address the remaining CHIP
shortfalls so that no State has insufficient funds to provide health
coverage for children. I am heartened by Senator Grassley's strong
commitment to the program that we will be able to work together in this
critical effort to shore up our Nation's safety net for low-income
children.
Mr. ROCKEFELLER. Your comments are helpful because I think Members
are concerned that accepting this CHIP shortfalls proposal means they
will be giving tacit approval to other provisions in the bill that they
don't really support--such as decreasing the CHIP allotment from 3
years to 2\1/2\ years, or putting restrictions on how States can use
the redistributed money, for example. But what I hear both of you
saying, I think, is that the CHIP provisions in this package are
causing a little bit of pain for everyone, but that the benefits of
getting something done now far outweigh the downsides and that nothing
in this CHIP package binds us as we move to reauthorize the program
next year.
Mr. GRASSLEY. I understand the concerns of our colleagues. Certainly,
there are those who think we should have gone further in this proposal.
There are Senators who support going from a 3-year allotment structure
to a 2-year allotment structure immediately. And there are Senators who
want to put greater limits on how CHIP dollars can be spent, to ensure
program spending prioritizes children first. Senator Baucus and I
developed a CHIP proposal that is somewhere in between but is a
proposal that meets our ultimate objective of keeping children covered.
We can have a policy debate about the merits of various proposals when
we reauthorize the program next year. Nothing in this package precludes
us from doing that.
Mr. BAUCUS. I expect the Finance Committee to have a deliberative
process on CHIP reauthorization early next year, where we can hear from
Members, Governors, CHIP directors, families and others about the CHIP
financing structure, the allotment timeframe, populations covered and
any other relevant issues of concern. As far as I'm concerned, we come
to this process with a clean slate and we will have an honest dialogue
about the future of this vital program. For right now, however, I hope
that we can pass this legislation, so that no child loses coverage
[[Page S11649]]
before we have a chance to reauthorize the program next year.
Mr. ROCKEFELLER. I thank my colleagues for their tireless efforts on
behalf of children, and I look forward to working with both of them to
address the remaining shortfalls early next year.
Mr. ENZI. Mr. President, today the Senate has once again affirmed its
commitment to strengthen the National Institutes of Health and its
important research to find better treatments and cures for all
diseases. Today, the Senate passed H.R. 6164, the National Institutes
of Health Reform Act of 2006. This important piece of legislation
provides needed reforms to the crown jewel of the Nation's biomedical
research enterprise, the National Institutes of Health.
This reauthorization builds upon the great initiatives and vision of
Dr. Zerhouni, the Director of NIH, by creating a common fund to support
cross-cutting trans-NIH research initiatives, such as those initiated
as part of Dr. Zerhouni's ``roadmap initiative''. This reform bill also
brings more transparency to the spending of this important agency. As
we recently doubled the NIH budget, it is important that the NIH and
Congress can plan and evaluate the efficiency and effectiveness of that
spending.
NIH is the steward of this Nation's biomedical research enterprise
and it is important we reevaluate the inner-workings of the agency to
ensure they are meeting this responsibility. The legislation passed
today is a fulfillment of our critical obligation to evaluate,
strengthen, and improve the NIH so that they can shoulder this burden.
This bill also includes the substance of the NIH Foundation
Improvement Act, which ensures the foundation has the resources and
ability to aid researchers in fulfilling NIH's mission to find better
treatments and cures for our most serious diseases. Most significantly,
these provisions clarify membership in the foundation's board of
directors and assures that the foundation receives funds to support its
operating expenses.
Every member of the House and Senate takes pride in the NIH and its
grantees. Through their work and vision, America has become the world
leader in biomedical research, and Americans benefit from the fruits of
these labors every day. I am confident that this legislation will help
NIH continue to be the engine that drives our understanding of
biomedical science and continue to be a source of pride.
Before closing, I would like to take this opportunity to acknowledge,
thank, and congratulate the people who have worked hard to craft,
draft, and pass this legislation. First, I would like to thank my
colleagues in the House and their staff for their hard work in passing
this critical legislation. It is hard to overstate their dedication and
work in getting this bill done.
Specifically, Chairman Barton and Representative Dingell worked
tirelessly crafting this legislation for months and getting the House
to pass it nearly unanimously. They have continued to work for the last
3 months to address every concern from Members here in the Senate.
Their staffs, Cheryl Jaeger, Katherine Martin, Ryan Long, John Ford and
Jessica McNiece, have worked patiently and persistently to reach
consensus that this bill is right policy at the right time. We
appreciate their dedication and cooperative work.
Further, I would like to acknowledge the Senate and House Legislative
Counsels, who worked hand in hand with staff to draft language as the
House and Senate worked to accommodate concerns. They worked many long
hours and all through the night last night to draft this language. In
particular, I would like to express my gratitude to Pete Goodlowe,
Warren Berg, and Bill Baird for their dedication and hard work which
enabled us to pass this bill.
I want to thank all the members of the Senate Committee on Health,
Education, Labor, and Pensions, especially my friend and ranking
member, Senator Kennedy, for his hard work and determination in seeing
this bill become law. I would also like to thank all of the staff,
without whom much of our progress would not have been possible.
I would also like to thank David Noll, Derrick Scholls, Caya Lewis,
and David Bowen of Senator Kennedy's staff for their hard work and late
nights.
Finally, I would like to thank my own staff, including Katherine
McGuire, my staff director, Ilyse Schuman, Greg Dean, Stephen Northrup,
Dave Schmickel, and Shana Christrup for their diligence and
determination as we worked to reach consensus on this important and
essential bill.
We anticipate the House will pass this bill later today, after which
it will be sent to the President's desk. I look forward to the exciting
biomedical breakthroughs that will result from the continued commitment
of the NIH to critical, lifesaving research.
Mr. CRAPO. Mr. President, I rise to comment briefly on the Tax Relief
and Health Care Act of 2006. This bill includes a number of important
provisions, including tax relief and reforms to the Medicare system. I
wish simply to highlight two sections for the record.
Section 103 contains an update of the composite rate component of the
basic case-mix adjusted prospective payment system for dialysis
services. The intent of this section is to provide an update of 1.6%
for a period of 1 year to the current composite rate for dialysis care.
This section does not address any other payment system modifications
for the ESRD Program. The GAO report is intended to explore the cost of
home dialysis and how to more effectively educate dialysis patients
about the possible advantages of home dialysis.
Section 110 relates to the reporting of anemia quality indicators for
Medicare Part B cancer anti-anemia drugs. The intent of this section is
to require the Secretary to develop a process through full notice and
comment rulemaking that requires providers to report hemoglobin or
hematocrit levels for patients being treated with cancer chemotherapy.
Nothing in this section is intended to require the Secretary to change
the coverage or payment rules for any products under Part B.
Mr. McCONNELL. Mr. President, I rise to express my concerns about
section 206 of the Tax Relief and Health Care Act of 2006. Under
current law, Medicare beneficiaries are only permitted to enroll in a
Medicare Advantage plan from November 15 to March 31. This provision
would allow Medicare fee-for-service beneficiaries to enroll in certain
Medicare Advantage plans at any time during 2007 or 2008, but only into
those Medicare Advantage plans that do not cover prescription drugs.
This is a significant change in policy, and I am concerned that this
could provide incentives for seniors to join plans that do not offer
prescription drug coverage. I am also troubled that this provision
could distort the thriving Medicare Advantage marketplace that is
serving seniors well today.
I also am concerned about the process by which this provision was
added to the underlying legislation. While the vast majority of the
Medicare provisions of the Tax Relief and Health Care Act of 2006 were
discussed and agreed to by the appropriate committees in the House and
Senate, it is my understanding that this provision was added to the
final package without the consent of the Finance Committee members who
negotiated on the Senate's behalf.
I want to make certain that our seniors are able to choose the
Medicare option that best meets their health care needs and I look
forward to working with my colleagues to ensure this provision does not
harm our Nation's Medicare beneficiaries.
Mr. LEVIN. Mr. President, this bill covers a number of important
areas. The so-called ``tax extenders'' provisions will continue a
number of expired or expiring tax incentives that are important to our
economy. These include the critical tax credit for research and
development done here in the U.S. The bill also extends the Welfare to
Work and the Work Opportunity Tax Credits, which encourage employers to
hire certain long-term family assistance recipients and members of
targeted groups such as high risk youth, families receiving food
stamps, SSI recipients, and qualified veterans. Another important
extension is the deduction for the out-of-pocket expenses of elementary
and secondary school teachers of up to $250 for books and other
supplies. And there is a deduction of up to
[[Page S11650]]
$4,000 for qualified tuition and related expenses. There is also a
provision to provide equity to the U.S.-flag ships operating in the
Great Lakes.
I am also pleased that this Congress is addressing the annual dilemma
of appropriate reimbursement for physicians treating Medicare patients.
The current Medicare reimbursement system is flawed, and without
action, doctors treating Medicare patients would have faced a 5%
reduction in reimbursement. I am pleased that this legislation will
halt those cuts and I urge the 110th Congress to take a serious look at
overall Medicare reimbursement so that we do not make this an annual
affair. I am also pleased that this legislation contains a six month
extension of the Medicare hospital wage index reclassification,
bringing additional temporary financial relief to over 100 Michigan
hospitals.
This bill also includes the permanent extension of Normal Trade
Relations (PNTR) to Vietnam which Congress has been granting on an
annual basis since December 2001. Vietnam is joining the WTO and the
United States is obligated to grant Vietnam permanent normal trade
relations in order to receive the market opening commitments that were
made by Vietnam as a condition of joining the WTO. As a member of the
WTO Vietnam will be subject to all of the WTO's international trade
rules. Currently, the United States provides PNTR to most countries,
but not Vietnam.
I also support the inclusion of the provisions of S. 3711, the Gulf
of Mexico Energy Security Act of 2006, in this package. I supported
this bill when it passed the Senate because I believe we need to move
forward to open up more areas for natural gas exploration to address
the increasingly tight natural gas supply in the U.S and its resulting
high prices.
Over the past six years, the tight natural gas supply and increasing
costs of natural gas has had a significant impact on consumers and
particularly on the U.S. manufacturing sector, which depends on natural
gas as both a fuel source and a feedstock and raw material. With U.S.
natural gas prices the highest in the industrialized world, many
companies have made decisions to move their manufacturing operations
offshore. Millions of manufacturing jobs have outsourced overseas
during this period.
Mr. President, I will support this bill because it contains many
important provisions. I do hope, however, that in the next Congress we
can take up legislation in a timely manner allowing for more study and
deliberation on important far-reaching provisions and avoid these last
minute omnibus packages. The process by which this omnibus package was
pulled together and unveiled at the eleventh hour is seriously flawed.
Pushing through an un-amendable, take-it-or-leave it package of
otherwise unrelated bills is not the way Congress should legislate. But
at least we are finally coming to address a number of important
provisions that we should have dealt with long ago.
Mr. REED. Mr. President, I have been a longtime supporter of these
tax credits and I am pleased that they are extended by this long
overdue bill before us tonight.
The tax credits included in this bill are significant both for
families and for businesses; these credits will help families send
their children to college, encourage businesses to hire individuals
working to get off welfare, and support research and development. The
IRS indicates that 19 million taxpayers will benefit from this relief.
Our economy benefits from these provisions and many taxpayers have
grown to rely on them. And those who benefit from these provisions need
certainty.
I am disappointed, however, by critical omissions and the inclusion
of some provisions about which I have serious concerns.
For starters, this package does not address the Alternative Minimum
Tax, AMT; a tax provision that, with no Congressional intervention,
will affect 37.1 million tax returns by 2010. Households are more
likely to pay the AMT if they have children or live in a high-tax state
because the AMT does not allow taxpayers to claim an exemption for
dependents as an itemized deduction for state taxes. By 2010, nearly 90
percent of married couples with two or more children and incomes
between $75,000 and $100,000 will pay the AMT.
The AMT is complicated, unfair, and no longer meets its intended
purpose. That is why in her 2003 annual report to Congress, National
Taxpayer Advocate Nina Olson identified the AMT as the most serious
problem encountered by taxpayers. According to Olson ``. . . that is
how the AMT appears to function--randomly, no longer with any logical
basis in sound tax administration or any connection with its original
purpose of taxing the very wealthy who escape taxation. Congress must
address the AMT before it bogs down tax administration and increases
taxpayers' cynicism to such a level that overall compliance declines.''
Also, the bill includes many ill-conceived provisions. I strongly
oppose the bill's inclusion of an expanded voucher program for the
District of Columbia. There is no doubt that our nation's capital faces
severe educational challenges. However, this expansion is an
unnecessary action that subverts the program's original intent to serve
solely low-income students, and continues federal government
subsidization of private and religious schools at the expense of public
education.
This is another attempt by the President and Republican leadership to
expand private school voucher programs, while reneging on our
fundamental commitment to public schools, where 90 percent of American
children receive their education. Instead of private school vouchers,
we should spend the dollars necessary to make the No Child Left Behind
reforms work. We should be focusing on educational issues that touch
the lives of all American students, not just a select few.
Also inserted in the bill is a considerable expansion of Health
Savings Accounts, HSAs. The provisions, which were never given full
consideration by either the Senate or House of Representatives, provide
yet another mechanism for high income individuals to shelter taxable
income under the guise of health care. An August Government
Accountability Office, GAO, report on tax filers who reported making
HSA contributions had an average income of $133,000 in 2004. The annual
survey of health care consumers by the Employee Benefit Research
Institute and the Commonwealth Fund found virtually no change in
enrollment in HSAs, nor did they find any measurable impact on the
rates of the uninsured in this country. While those who support these
extensions, which will cost taxpayers close to a billion dollars over
the next decade, will argue that they will help expand these insurance
products to more Americans, in reality they will benefit only those
Americans wealthy enough to take advantage of them.
The bill does contain some essential health-related provisions.
Specifically, it includes another temporary update in the reimbursement
rate for physicians under Medicare. While this package reverses the
projected 5.1 percent cut for 2007, this Congress must take action next
year to bring greater stability and predictability to the Medicare
physician payment formula than currently exists. Nevertheless, this
provision ensures that elderly and disabled Medicare patients will
continue to have access to their providers.
While this bill provides a 1-year extension of the moratorium on
Medicare therapy caps, many other needed Medicare and Medicaid
provisions have been omitted. For instance, the bill does not include a
moratorium on impending reductions in reimbursements for imaging
services.
However, I would commend the architects of the legislation for
carving out unexpended monies available in the Medicare advantage
stabilization fund to finance the provisions that were included instead
of resorting to cuts in reimbursements to individual Medicare providers
groups.
I am further disappointed that this bill allows for exploration of
the outer continental shelf. This provision will not provide energy
security to the United States. Our nation needs a comprehensive energy
policy that reduces dependency on fossil fuels through increased energy
efficiency, greater investment in renewable energy, and development of
alternative fuels to replace oil. This provision is also unsound fiscal
policy. It would mandate that almost 38 percent of revenue from federal
resources generated by new leases in the Gulf of Mexico be given to
four states--Alabama, Louisiana, Mississippi, and Texas. These are
revenues
[[Page S11651]]
that currently would be provided to the United States Treasury for the
benefit of the Nation as a whole. Reducing revenue to the Treasury
means that we, as a nation, will have fewer resources available in the
future to respond to a call for help should there be another
devastating natural disaster or terrorism attack.
Unfortunately, the majority played political games to get us to this
point. We should have passed this legislation long ago. Instead, we are
now faced with passing a bill that contains important provisions but
also a number of others that I would have opposed had they been offered
on their own merits. Despite this bill's shortcomings, I will support
it because it extends tax credits that will truly benefit countless
Americans and contains an important physician reimbursement fix. I will
work in the new Congress to address the bill's shortcomings.
Mr. FRIST. I ask unanimous consent the amendment at the desk be
agreed to, the bill, as amended, be read the third time and passed, the
motion to reconsider be laid upon the table, and any statements be
printed in the Record.
The PRESIDING OFFICER. Without objection, it is so ordered.
The amendment (No. 5238) was agreed to.
(The amendment is printed in today's Record under ``Text of
Amendments.'')
The amendment was ordered to be engrossed and the bill to be read a
third time.
The bill (H.R. 6164), as amended, was read the third time and passed.
statement of managers
Mr. GRASSEY. Mr. President, I ask unanimous consent that a manager's
statement be printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:
Statement of Managers
DIVISION B--MEDICARE AND OTHER HEALTH PROVISIONS
section 1. short title of division
Current law
No Provision.
Explanation of provision
This division may be cited as the ``Medicare Improvements
and Expansion Act of 2006''.
Title I--Medicare Improved Quality and Provider Payments
section 101. Physician payment and quality improvement
Current law
Medicare payments for services of physicians and certain
nonphysician practitioners are made on the basis of a fee
schedule. The fee schedule assigns relative values to
services that reflect physician work (i.e., the time, skill,
and intensity it takes to provide the service), practice
expenses, and malpractice costs. The relative values are
adjusted for geographic variations in costs. The adjusted
relative values are then converted into a dollar payment
amount by a conversion factor. The conversion factor for 2006
is $37.8975.
The conversion factor is the same for all services. It is
updated each year according to a formula specified in law.
The intent of the formula is to place a restraint on overall
spending for physicians' services. Several factors enter into
the calculation of the formula. These include: (1) the
sustainable growth rate (SGR) which is essentially a
cumulative target for Medicare spending growth over time
(with 1996 serving as the base period); (2) the Medicare
economic index (MEI) which measures inflation in the inputs
needed to produce physicians services; and (3) the update
adjustment factor which modifies the update, which would
otherwise be allowed by the MEI, to bring spending in line
with the SGR target. In no case can the adjustment factor be
less than minus seven percent or more than plus three
percent.
The law specifies a formula for calculating the SGR. It is
based on changes in four factors: (1) estimated changes in
fees; (2) estimated change in the average number of Part B
enrollees (excluding Medicare Advantage beneficiaries); (3)
estimated projected growth in real gross domestic product
(GDP) growth per capita; and (4) estimated change in
expenditures due to changes in law or regulations. In order
to even out large fluctuations, MMA changed the GDP
calculation from an annual change to an annual average change
over the preceding 10 years (a ``10-year rolling average'').
The SGR target is not a limit on expenditures. Rather, the
fee schedule update reflects the success or failure in
meeting the target. If expenditures exceed the target, the
update for a future year is reduced. This is what occurred
for 2002. It was also slated to in subsequent years; however,
legislation kept this from occurring. Most recently, the
Deficit Reduction Act froze the 2006 conversion factor at the
2005 level. A negative 5% percent update is slated to occur
in 2007.
Explanation of provision
The conversion factor for 2007 would be the conversion
factor otherwise applicable for 2007 divided by the product
of: (i) 1 plus the Secretary's estimate of the percentage
increase in the MEI for 2007 (divided by 100), and (ii) 1
plus the Secretary's estimate of the update adjustment factor
for 2007. These changes would not be considered in the
computation of the conversion factor for 2008.
The provision would also implement a voluntary quality
reporting system for Medicare payments for covered
professional services tied to the reporting of claims data.
Physicians and other eligible professionals (including
physician assistants, nurse practitioners, clinical nurse
specialists, certified registered nurse anesthetists,
certified nurse-midwives, clinical social workers, clinical
psychologists, registered dietitians or nutritional
professionals as defined under current law, physical
therapists, occupational therapists, and qualified speech-
language pathologists) who report the quality information
would be eligible for a bonus incentive payment for services.
For 2008, the Secretary would address a mechanism whereby an
eligible professional could provide data on quality measures
through an appropriate medical registry (such as the Society
of Thoracic Surgeons National Database) as identified by the
Secretary.
For covered professional services furnished beginning July
1, 2007 and ending December 31, 2007, the quality reporting
measures are those identified as physician quality measures
under the CMS Physician Voluntary Reporting Program (PVRP) as
published on the CMS public website as of the date of
enactment of this provision. The Secretary may modify these
quality measures if changes are based on the results of a
consensus-process meeting in January of 2007 and if such
changes are published on the CMS website by April 1, 2007.
The Secretary may subsequently refine the quality measures
(without notice or opportunity for public comment) up until
July 1, 2007 by publishing modifications or refinements to
previously published quality measures but may not change the
quality measures.
Eligible professionals who (1) furnish services for which
there are established quality measures as determined by this
provision and (2) satisfactorily submit quality measures
would be paid a single additional bonus payment amount equal
to 1.5% of the allowed charges for covered professional
services furnished during the reporting period. The bonus
incentive payments would be paid from the Supplemental
Medical Insurance Trust Fund (Part B). These bonus incentive
payments would not be taken into account in the calculations
and determination of payments for providers in health
professional shortage areas or Physician Scarcity Areas, nor
would these bonus payments be taken into account in computing
allowable charges under this subsection.
The Secretary would presume that if an eligible
professional submits data for a measure, then the measure is
applicable to the professional. However, the Secretary may
validate (by sampling or other means as the Secretary
determines to be appropriate) to determine if an eligible
professional reports measures applicable to such professional
services. If the Secretary determines that an eligible
professional has not successfully reported applicable
measures, the Secretary would not pay that professional the
bonus.
Satisfactory reporting of data determines whether the
provider is eligible for the bonus payment. If there are no
more than 3 quality measures that are applicable to the
professional services furnished, the provider must report
each measure for at least 80% of the cases to meet the
criteria. If there are 4 or more quality measures that are
applicable, the provider must report at least 3 of the
quality measures for at least 80% of the cases.
The provision also places a limit on bonus payments. No
provider would receive payments in excess of the product of
the total number of quality measures for which data are
submitted and three times the average per measure payment
amount. The average per measure payment amount would be
estimated by the Secretary and would equal the total amount
of allowed charges under Medicare part B for all covered
professional services furnished during the reporting period
on claims for which quality measures are reported divided by
the total number of quality measure for which data are
reported during the reporting period under the physician
reporting system.
The Secretary would provide for education and outreach to
eligible professionals regarding these changes. The Secretary
would implement these provisions acting through the
Administrator of the Centers for Medicare and Medicaid
services.
This provision would allow no administrative or judicial
review, under the existing Medicare appeals process or
through a Provider Reimbursement Review Board as currently
codified in statute, of the determination of measures,
satisfactory reporting, payment limitation, or bonus
incentive payment. A determination under the provisions of
this section would not be treated as a determination under
current appeals processes for Medicare.
For 2008, the quality measures would be selected from
measures adopted or endorsed by a consensus organization
(such as the National Quality Forum or AQA, originally known
as the Ambulatory Care Quality Alliance) that includes
measures that have been submitted by a physician specialty
developed through a consensus-based process as identified by
the Secretary. Such measures shall
[[Page S11652]]
include structural measures, such as the use of electronic
health records and electronic prescribing technology. The CMS
administrator would publish a proposed set of quality
measures for 2008 in the Federal Register no later than
August 15, 2007 with a public comment period. The final set
of measures appropriate for eligible professionals to use to
submit quality data in 2008 would be published no later than
November 15, 2007.
The Secretary would be required to establish a Physician
Assistance and Quality Initiative Fund which would be
available to the Secretary for physician payment and quality
improvement initiatives. Such initiatives may include
application of an adjustment to the update to the conversion
factor. The amount available to the Fund would be $1.35
billion for 2008. The Secretary would be required to provide
for expenditures from the Fund for the obligation of the
entire amount (to the maximum extent feasible) for payment
for physicians services furnished in 2008. The specified
amount available to the Fund would be made to the Fund from
the Part B trust fund as expenditures are made from the Fund.
The amounts in the Fund are to be available in advance of
appropriations, but only if the total amount obligated to the
Fund does not exceed the amount available to it. The
Secretary may obligate funds from the Fund only if the
Secretary determines (and the CMS Chief actuary and the
appropriate budget officer certifies) that there are
sufficient amounts available in the Fund. If the expenditures
from the fund affect the conversion factor for a year, this
would not affect the computation of the conversion factor for
a subsequent year.
The Secretary would be required to transfer $60 million
from the Part B trust fund to the CMS Program Management
Account for the period of FY 2007, FY 2008, and FY 2009 for
the purposes of implementing this section.
Section 102. Extension of floor on Medicare work geographic adjustment
Current law
Medicare's physician fee schedule assigns relative values
to services that reflect physician work (i.e., the time,
skill, and intensity it takes to provide the service),
practice expenses, and malpractice costs. The relative values
are adjusted for geographic variations in costs. The adjusted
relative values are then converted into a dollar payment
amount by a conversion factor.
The geographic adjustment factors are indices that reflect
the relative cost difference in a given area in comparison to
a national average. An area with costs above the national
average would have an index greater than 1.00 while an area
with costs below the average would have an index below 1.00.
The physician work geographic adjustment factor is based on a
sample of median hourly earnings in six professional
specialty occupational categories. Unlike the other
geographic adjustments, the work adjustment factor reflects
only one-quarter of the cost differences in an area. The
practice expense adjustment factor is based on employee
wages, office rents, medical equipment and supplies. The
malpractice adjustment factor reflects differences in
malpractice insurance costs. The Secretary is required to
periodically review and adjust the geographic indices.
MMA required the Secretary to increase the value of any
work geographic index that was below 1.00 to 1.00 for
services furnished on or after January 1, 2004 and before
January 1, 2007.
Explanation of provision
The requirement is extended for an additional year, for
services provided before January 1, 2008.
Section 103. Update of the composite rate component of the basic case-
mix adjusted prospective payment system for dialysis services
Current law
The Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) required the Secretary to
establish a basic case-mix adjusted prospective payment
system for dialysis services furnished either at a facility
or in a patient's home, for services furnished beginning on
January 1, 2005. The basic case-mix adjusted system has two
components: (1) the composite rate, which covers services,
including dialysis; and (2) a drug add-on adjustment for the
difference between the payment amounts for separately
billable drugs and biologicals and their acquisition costs,
as determined by Inspector General Reports.
The Secretary is required to update the basic case-mix
adjusted payment amounts annually beginning with 2006, but
only for that portion of the case-mix adjusted system that is
represented by the add-on adjustment and not for the portion
represented by the composite rate. The DRA increased the
composite rate component of the basic case-mix adjusted
system for services beginning January 1, 2006 by 1.6%, over
the amount paid in 2005. For 2006, the base composite rate is
$130.40 for independent ESRD facilities and $134.53 for
hospital-based ESRD facilities. The total drug add-on
adjustment, with inflation, is 14.5%.
Explanation of provision
The composite rate component of the basic case-mix adjusted
system shall be increased by 1.6 percent above the 2005 rate,
for services furnished on or after January 1, 2006 and before
April 1, 2007. For services furnished on or after April 1,
2007, the composite rate component of the basic case-mix
adjusted system shall by increased by 1.6 percent, above the
amount of such rate for services furnished on March 31, 2007.
Not later than January 1, 2009, GAO shall submit a report
to Congress on the costs for home hemodialysis treatment and
patient training for both home hemodialysis and peritoneal
dialysis. The report shall include recommendations for a
payment methodology that measures, and is based on, the cost
of providing such services and takes into account the case
mix of patients.
Section 104. Extension of Treatment of certain physician pathology
services under Medicare
Current law
In general, independent laboratories cannot directly bill
for the technical component of pathology services provided to
Medicare beneficiaries who are inpatients or outpatients of
acute care hospitals. The Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection Act of 2000 (BIPA)
permitted independent laboratories with existing arrangements
with acute care hospitals to bill Medicare separately for the
technical component of pathology services provided to
inpatients and outpatients. The arrangement between the
hospital and the independent laboratory had to be in effect
as of July 22, 1999. The direct payments for these services
applied to services furnished during 2001 and 2002. MMA
applied the provision to services furnished during 2005 and
2006.
Explanation of provision
The provision is extended through 2007.
Section 105. Extension of Medicare reasonable costs payments for
certain clinical diagnostic laboratory tests furnished to hospital
patients in certain rural areas
Current law
Generally, hospitals that provide clinical diagnostic
laboratory tests under Part B are reimbursed under a fee
schedule. MMA specified that hospitals with under 50 beds in
qualified rural areas (low density population rural areas)
would receive 100% reasonable cost reimbursement for clinical
diagnostic tests covered under Part B that are provided as
outpatient services. The provision applied to services
furnished during a cost-reporting period beginning during the
2-year period starting July, 1, 2004.
Explanation of provision
The provision is modified to apply to services furnished
during a cost-reporting period beginning during the 3-year
period starting July 1, 2004. The provision is effective as
if included in the enactment of MMA.
Section 106. Hospital Medicare reports and clarifications
(a) Correction of mid-year reclassification expiration
Current law
Section 508 of the Medicare Prescription Drug, Improvement
and Modernization Act of 2003 (MMA) established a one-time-
only appeals procedure to provide relief for certain
hospitals that could not meet the existing reclassification
criteria used by the Medicare Geographic Classification
Review Board (MGCRB). The Section 508 reclassifications
appeals were heard by the MGCRB and were not subject to
further administrative or judicial review. The Section 508
reclassifications are effective for 3 years, beginning on
April 1, 2004 and ending on March 31, 2007. Congress
allocated $900 million over 3 years to fund this provision.
Generally speaking, unless otherwise specified by law, the
MGCRB's classification decisions are required to have a
budget neutral effect in the inpatient prospective payment
system (IPPS).
Explanation of provision
The provision would extend wage index reclassifications
that expire on March 31, 2007 until September 30, 2007. This
provision would not be implemented in a budget neutral
fashion.
(b) Revision of the Medicare wage index classification
system
Current law
As directed by Medicare statute, the amount of a hospital's
operating and capital payments will vary according to the
relative level of hospital wages in its geographic area
compared to the national average. The geographic areas or
hospital labor markets that have been used by Medicare are
urban areas as established by the Office of Management and
Budget (OMB). Essentially, a hospital's payment will depend
upon whether it is in an urban area (and if so, which one)
and the wage data reported by the hospitals in that area.
Counties that are not in an urban area are grouped into one
statewide rural labor market. Also, with modifications, the
hospital wage data are used to adjust for geographic cost
differences in Medicare's payment systems for other services,
such as inpatient rehabilitation facility (IRF), long-term
care hospital (LTCH), home health agency (HHA), skilled
nursing facility (SNF), and hospice care. Unlike these other
providers, IPPS hospitals have an administrative process,
through appeals to the Board (the Board), to reclassify to
different geographic areas. Other statutory provisions
affecting hospital's geographic designation also have been
established.
Explanation of provision
The Medicare Payment Advisory Commission (MedPAC) would be
required to submit a report to Congress no later than June
30, 2007 on the wage index classification system used in
Medicare's prospective payment systems,
[[Page S11653]]
including IPPS. This report would include recommendations for
alternatives to the current methods used to compute the wage
index. $2 million in funds in the Treasury would be
appropriated to MedPAC for FY 2007 for these activities. The
Secretary would be required to include in the proposed rule
making process for FY 2009 one or more proposals to revise
the IPPS wage adjustment, after taking into account MedPAC's
recommendations. The proposals would consider problems
associated with labor market definitions; modification or
elimination of geographic reclassifications and other
adjustments; the use of Bureau of Labor Statistics data to
calculate relative wages; minimizing variations in wage
index adjustments between and within metropolitan
statistical areas and rural areas; the feasibility of
applying all components of the proposal to other settings,
including HHAs and SNFs; methods to minimize the
volatility of wage index adjustments while maintaining the
budget neutrality; the effect on health care providers and
on each region of the country; implementation of proposal,
including the transition methods; and occupational mix
issues such as staffing practices, effect on quality of
care and alternative recommendations.
(c) Elimination of unnecessary report
The Secretary is required to submit a report to Congress
that includes an initial estimate of the percentage update
(change factor) in the per discharge payment amounts. The
Secretary's estimate is required to take into consideration
the recommendations of MedPAC and may vary for hospitals in
different geographic areas.
Explanation of provision
This provision would eliminate the requirement that the
Secretary include recommendations with respect to the update
factors no later than March 1 before the beginning of the
fiscal year.
section 107. extension of payment rule for brachytherapy
Current law
The Medicare Prescription Drug, Improvement and
Modernization Act of 2003 (MMA) established that
brachytherapy devices consisting of radioactive sources (or
seeds) would be paid on the basis of a hospital's cost for
such device (computed by reducing a hospital's charges to
costs) for services furnished starting January 1, 2004 until
January 1, 2007. The Secretary was directed to create
additional groups of covered OPD services that classify such
devices separately from other services (or group of services)
in a manner that reflects the number, isotope, and
radioactive intensity, including separate groups for
palladium-103 and iodine-125 devices. Starting January 1,
2007, CMS will continue to pay separately for brachytherapy
sources, but will base payment on the source-specific median
costs. CMS declined to create new brachytherapy source codes
to differentiate stranded from unstranded brachytherapy
sources.
Explanation of provision
This provision would extend payment for brachytherapy
sources on the basis of a hospital's charges adjusted to cost
until January 1, 2008. The provision also directs the
Secretary to create additional groups of covered OPD services
for stranded and nonstranded brachytherapy devices furnished
on or after July 1, 2007. These provisions may be implemented
by program instruction or otherwise.
section 108. payment process under the competitive acquisition program
(cap)
Current law
MMA revised the way Medicare pays for Part B drugs.
Beginning in 2005, payments for these drugs are based on an
average sales price (ASP) payment methodology, which sets
payments at the weighted average ASP plus 6%; the Secretary
has the authority to reduce the ASP payment amount if the
widely available market price is significantly below the ASP.
Alternatively, beginning in 2006, drugs can be provided
through a newly established competitive acquisition program
(CAP). The intent of the program is to enable physicians to
acquire certain drugs from an approved CAP vendor thereby
enabling them to reduce the time they spend buying and
billing for drugs.
Explanation of provision
The provision deletes the requirement that payments to CAP
contractors are conditioned upon the administration of the
drugs and biologicals. The provision specifies that payment
may only be made to the contractor upon receipt of a claim
for a drug or biological supplied by the contractor for
administration to a beneficiary. Further, the Secretary is
required to establish a post-payment review process to assure
that payment is made for a drug or biological only if it has
been administered. The process of postpayment review may be
established by program instruction or otherwise and may
include the use of statistical sampling. The Secretary is
required to recoup, offset or collect any overpayments
determined by the Secretary under this process.
The section further clarifies that nothing in this
provision is to be construed as requiring any additional
competition by entities under the CAP program. Further the
provision is not to be construed as requiring any additional
process for elections by physicians under the program or
additional selection by a selecting physician of a CAP
contractor. The provision applies to payments for drugs and
biologicals supplied on or after April 1, 2007. Additionally,
the provision applies on or after July 1, 2006 and before
April 1, 2007, for claims that are paid before April 1, 2007.
section 109. quality reporting for hospital outpatient services and
ambulatory surgical center services
(a) Outpatient hospital services
Current law
Each year the hospital outpatient department (OPD) fee
schedule is increased by a factor that is generally based on
the hospital market basket (MB) percentage increase. In
certain years, the MB has been reduced by percentage points
as specified by statute.
Explanation of provision
Starting in 2009 and for each subsequent year, a hospital
paid under the inpatient prospective payment system (IPPS)
that does not submit required measures will receive an OPD
fee schedule increase of the MB minus 2.0 percentage points.
A reduction under this provision would only apply to payments
for the year involved and would not be taken into account
when computing the OPD fee schedule increase in a subsequent
year.
Each IPPS hospital is required to submit data on measures
under this section in the form, manner, and timing specified
by the Secretary. The Secretary would be required to develop
appropriate measures for the measurement of the quality of
care (including medication errors) furnished by hospitals in
outpatient settings and that reflect consensus among affected
parties. To the extent feasible and practicable, the measures
shall include those set forth by one or more national
consensus building entities. Nothing would prevent the
Secretary from selecting the IPPS quality measures or a
subset of such measures. The Secretary would be able to
replace any measures as appropriate, such as where all
hospitals are effectively in compliance or the measures have
subsequently been shown not to represent the best clinical
practice.
The Secretary would be required to establish procedures for
making the submitted data available to the public. These
procedures would ensure that a hospital has the opportunity
to review data prior to being made available to the public.
The Secretary would be required to report quality measures of
process, structure, outcome, patients' perspective on care,
efficiency, and costs of care on the Internet website of the
Centers for Medicare and Medicaid Services. Other conforming
amendments would also be established.
(b) Application to ambulatory surgical centers
Current law
Presently, Medicare pays for surgery-related facility
services in an ambulatory surgical center (ASC) based on a
fee schedule. The Medicare Prescription Drug, Improvement,
and Modernization Act of 2006 (MMA) required the Secretary to
implement a revised payment system for ASCs no later than
January 1, 2008, taking into account recommendations issued
by a required report from the Government Accountability
Office (GAO). The GAO report, which has just been issued, was
required to examine the relative costs of ASC services to
those in hospital outpatient departments. GAO was also
required to recommend whether CMS should use the outpatient
prospective payment system as the basis for the revised ASC
system. Total payments under the new system should be equal
to total projected payments under the old system.
Explanation of provision
In the revised payment system, the Secretary would be able
to provide for a reduction in any annual update of 2.0
percentage points for failure to report required quality
measures. A reduction under this provision would only apply
to payments for the year involved and would not be taken into
account when computing any annual increase factor in
subsequent years. Except as otherwise provided by the
Secretary, the provisions of subparagraphs (B), (C), (D), and
(E) of the newly established Section 1833(t)(17) concerning
the form and submission of data, the development of
outpatient measures, the replacement of measures, and the
availability of quality measures in a hospital outpatient
setting would apply to ASC services.
(c) Effective date
Current law
No provision.
Explanation of provision
The amendments made by the section would apply to payment
for services furnished starting January 1, 2009.
section 110. reporting of anemia quality indicators for medicare part b
cancer anti-anemia drugs
Current law
Medicare Part B covers certain drugs used as anticancer
chemotherapeutic agents, and certain oral anti-emetic drugs
and biologicals used as part of an anticancer
chemotherapeutic regimen. Medicare also covers certain drugs
and biologicals to counter anemia for chronic kidney disease
and cancer patients. At present, Medicare Part B requires
hemoglobin or hematocrit levels to be reported only for
certain chronic kidney disease (dialysis) patients, but not
for cancer patients. MedPAC has recommended that the
hemoglobin or hematocrit levels be reported for patients
receiving anti-anemia drugs.
Explanation of provision
The provision requires that all Part B claims submitted for
drugs for treatment of
[[Page S11654]]
anemia in connection with cancer chemotherapy include the
hemoglobin or hematocrit levels for the individual. The
information is to be submitted in the form and manner
specified by the Secretary after full notice-and-comment
rulemaking as part of the physician fee schedule update rule
in 2007. The provision applies to drugs and biologicals
furnished on or after January 1, 2008.
section 111. clarification of hospice satellite designation
Current law
Section 1814(i)(2)(A) of the Social Security Act limits
total Medicare payment amounts to individual hospice
providers by an absolute dollar amount, or ``cap amount.''
This amount is based on the number of Medicare patients the
agency serves and is calculated by dividing total payments to
a hospice per year by the total number of beneficiaries
served to get the per beneficiary payment amount. If the
per beneficiary payment amount does not exceed the cap
amount, the hospice may retain all payments. If the result
exceeds the cap amount, the hospice must repay excess
funds to the Medicare program. For purposes of calculating
whether or not a hospice exceeds the cap amount,
increasing the number of beneficiaries a hospice serves
reduces the per beneficiary payment amount. A lower per
beneficiary payment amount reduces the likelihood that a
hospice will exceed the annual hospice cap and be required
to repay excess funds to the Medicare program.
Explanation of provision
For purposes of calculating the hospice cap for 2004, 2005
and 2006 and for hospice care provided after November 1, 2003
and before December 27, 2005, this provision would designate
hospice with provider number 290-1511 as a multiple location
of hospice with provider number 29-1500.
TITLE II--MEDICARE BENEFICIARY PROTECTIONS
Section 201. Extension of exceptions process for Medicare therapy caps
Current law
The Balanced Budget Act of 1997 established annual per
beneficiary payment limits for all outpatient therapy
services provided by non-hospital providers. The limits
applied to services provided by independent therapists as
well as to those provided by comprehensive outpatient
rehabilitation facilities (CORFs) and other rehabilitation
agencies. The limits did not apply to outpatient services
provided by hospitals.
Beginning in 1999, there were two beneficiary limits. The
first was a $1,500 per beneficiary annual cap for all
outpatient physical therapy services and speech language
pathology services. The second was a $1,500 per beneficiary
annual cap for all outpatient occupational therapy services.
Beginning in 2002, the amount would increase by the Medicare
economic index (MEI) rounded to the nearest multiple of $10.
The Balanced Budget Refinement Act of 1999 (BBRA) suspended
application of the limits for 2000 and 2001. The Medicare,
Medicaid, and SCHIP Benefits Improvement and Protection Act
of 2000 (BIPA) extended the suspension through 2002.
Implementation of the provision was delayed until September
2003. The caps were implemented from September 1, 2003
through December 7, 2003. MMA reinstated the moratorium from
December 8, 2003 through December 31, 2005.
The caps went into effect again beginning January 1, 2006.
The 2006 caps are each $1,740. However, DRA required the
Secretary to implement an exceptions process for expenses
incurred in 2006. Under the process, a part B enrollee, or a
person acting on behalf of the enrollee, can request an
exception from the physical therapy and occupational therapy
caps. The individual may obtain such exception if the
provision of services is determined medically necessary. The
exceptions process only applies for 2006.
Explanation of provision
The provision extends the exceptions process through 2007.
Section 202. Payment for administration of part D vaccines
Current Law
Medicare Part B covers pneumoccoccal vaccine and its
administration, influenza vaccine and its administration, and
hepatitis B vaccine and its administration when furnished to
a high or intermediate risk individual. Medicare Part D
covers other vaccines licensed under the Public Health
Service Act.
Explanation of provision
The provision specifies that during 2007, the
administration costs for a vaccine paid under Part D are to
be paid under Part B as if it were the administration of a
hepatitis B drug covered under Part B. Beginning in 2008,
Part D coverage will include the administration costs.
Section 203. OIG study of never events
Current law
No provision.
Explanation of provision
The Office of the Inspector General (OIG) in the Department
of Health and Human Services would be required to conduct a
study on the incidence of never events for Medicare
beneficiaries, including types of such events and payments by
any party, including beneficiaries, of such events. This
study would also include the extent to which Medicare paid,
denied or recouped payment for such services as well as the
administrative processes of the Centers for Medicare and
Medicaid Services (CMS) to identify such events and to deny
or recoup associated payments. The OIG would be required to
audit a representative sample of claims and medical records
of the events; would be able to request access to claims and
records from any Medicare contractor; and would not be able
to release individually identifiable or facility specific
information. The OIG would be required to submit a report to
Congress no later than two years from enactment. This report
would include recommendations for legislative or
administrative action on the processes to identify, deny or
recoup payments for never events. The report will also
provide a recommendation on a potential process for public
disclosure of never events that ensures patient privacy
and permits the use of disclosed information for root
cause analysis. $3 million of funds in the Treasury will
be appropriated which will be available until January 1,
2010. Never events are those that are listed and endorsed
as ``serious reportable events'' by the National Quality
Forum as of November 16, 2006.
Section 204. Medicare medical home demonstration project
Current law
No provision.
Explanation of provision
The Secretary is required to establish a medical home
demonstration project in Medicare law for the purpose of
redesigning the healthcare delivery system to provide
targeted, accessible, continuous and coordinated, family-
centered care to high-need populations (i.e., those with
multiple chronic illnesses that require regular monitoring,
advising, or treatment).
Under the project, case management fees would be paid to
personal physicians, and incentive payments would be paid to
physicians participating in practices that provide ``medical
home'' services. Medical homes are physician practices in
charge of targeting beneficiaries for project participation.
They are responsible for: (1) providing safe and secure
technology to promote patient access to personal health
information; (2) developing a health assessment tool for the
targeted individuals; and (3) providing training for
personnel involved in the coordination of care.
The project is to operate for three years in urban, rural,
and underserved areas in up to 8 states and would include
physician practices with fewer than three full-time
equivalent physicians, as well as larger practices,
particularly in rural and underserved areas.
In addition to meeting Medicare requirements for
physicians, personal physicians who provide first contact and
continuous care for their patients must be board certified.
Personal physicians must also have staff and resources to
manage the comprehensive and coordinated health care of each
of their patients. Participating physicians may be
specialists or subspecialists for patients requiring ongoing
care for specific conditions, multiple chronic conditions
(e.g., severe asthma, complex diabetes, cardiovascular
disease, and rheumatologic disorder), or for those with a
prolonged illness.
Personal physicians must perform (or provide for the
performance of): (1) advocates for and provides ongoing
support, oversight, and guidance to implement a plan of care;
that provides an integrated, coherent, cross discipline plan
for ongoing medical care developed in partnership with
patients and including all other physicians furnishing care
to the patient involved and other appropriate medical
personnel or agencies (such as home health agencies); (2)
uses evidence-based medicine and clinical decision support
tools to guide decision-making at the point-of-care (based on
patient-specific factors); (3) uses health information
technology that may include remote monitoring and patient
registries; and (4) encourages patients to engage in
management of their own health through education and support
systems.
Payments for care management to personal physicians are to
be provided under a care management fee under section 1848 of
the Social Security Act. The Secretary would be required to
develop a care management fee code and a value for these
payments using the relative value scale update committee
(RUC) process.
Payments for a medical home shall be based on the payment
methodology applied to physician group practices under
section 1866A of the Social Security Act. Under this
methodology, 80% of Medicare reductions (determined by using
assumptions with respect to the reductions in the occurrence
of health complications, hospitalization rates, medical
errors, and adverse drug reactions) resulting from the
medical home participation (as reduced by the total project-
related care management fees), would be paid to the medical
home. Project payments are to be paid from part B.
The Secretary would be required to provide a yearly project
evaluation and submit it to Congress on a date specified by
the Secretary. In addition, the Secretary would be required
to submit to Congress a project evaluation no later than one
year after project completion.
Section 205. Medicare DRA technical corrections
(a) PACE clarification
Current law
The Secretary appropriated $10 million for FY2006 for the
outlier funds for rural PACE providers. Outlier costs are
those inpatient and other costs in excess of $50,000 incurred
[[Page S11655]]
within a given 12-month period by a PACE provider for an
eligible participant who resides in a rural area. These
appropriated funds would remain available for expenditure
through FY2010.
Explanation of provision
The amendment clarifies that the appropriated $10 million
would be applied to fiscal years 2006 through 2010, rather
than only for FY2006. It also specifies that the funds would
remain available for obligation, rather than for expenditure,
through FY2010.
(b) Miscellaneous technical corrections
(1) Correction of margin (section 5001)
Current law
No provision.
Explanation of provision
Section 1886(b)(3)(B) of the Social Security Act (42 U.S.C.
1395ww(b)(3)(B)), as amended by section 5001(a) of the
Deficit Reduction Act of 2005 (Public Law 109-171), is
amended by moving clause (viii) (including subclauses (I)
through (VII) of such clause) 6 ems to the left.
(2) Reference Correction (Section 5114)
Current law
This P.L. 109-171 provision modified the first sentence of
section 1842(b)(6)(F) of the Social Security Act to add a new
paragraph H to 1842(b)(6) so that a federally qualified
health center (FQHC) would be paid directly for FQHC services
provided by a health care professional under contract with
that FQHC.
Explanation of provision
Instead of modifying section 1842(b)(6)(F) to add paragraph
H, the amendment would modify section 1842(b)(6) of the
Social Security Act.
(c) Effective date
These amendments would become effective as if they had been
included in DRA 2005, enacted on February 8, 2006.
Sec. 206. Continuous Open Enrollment into Certain Medicare Advantage
Plans
Current law
Individuals entitled to Medicare part A or enrolled in part
B can choose to receive Medicare benefits by enrolling in a
Medicare Advantage plan. Individuals enrolled in a Medicare
Advantage (MA) plan who also want to receive Medicare
prescription drug coverage may obtain prescription drug
coverage through that MA plan. MA enrollees may not also
enroll in a stand-alone prescription drug plan under part D,
except for: (1) enrollees in private fee-for-service MA plans
that do not offer qualified prescription drug coverage or (2)
enrollees in Medical Savings Accounts MA plans.
In general, individuals can make a coverage election during
the annual election period, which in 2006 and beyond, begins
on November 15 and ends on December 31. During this time,
beneficiaries can elect to receive benefits through original
Medicare fee-for-service (FFS) program or an MA plan.
Individuals also can elect to enroll in a stand-alone
prescription drug plan or an MA plan that offers drug
coverage. Under certain circumstances, an individual may be
afforded a special election period outside of the annual
election period, during which time they can change their
coverage election.
Beginning in 2007, individuals can change their coverage
elections one time between January 1 and March 31.
Permissible election changes during this period include: FFS
to an MA plan; MA plan to FFS; MA plan to a different MA
plan; FFS with stand-alone prescription drug coverage to an
MA-PD; MA-PD to a different MA-PD; and MA-PD to FFS with a
stand-alone prescription drug plan. With respect to PFFS
plans, the permissible election changes include FFS with a
stand-alone PDP to a PFFS or MSA plan with the same stand-
alone PDP or FFS with a stand-alone PDP to a PFFS-PD.
Individuals who did not elect prescription drug coverage
during the annual election period cannot elect prescription
drug coverage during this one-time change period.
Explanation of provision
For 2007 and 2008, the provision modifies current law such
that an unenrolled fee-for-service individual can make a one-
time change to their coverage election on any date during the
year. An unenrolled individual is defined as an individual
who is receiving benefits under original Medicare FFS, is not
enrolled in an MA plan on such date; and as of such date is
not otherwise eligible to elect to enroll in an MA plan.
Permissible coverage election changes for an unenrolled
individual include: (1) FFS to an MA plan with no drug
coverage and (2) FFS with a stand-alone prescription drug
plan to an MA plan with the same stand-alone prescription
drug plan. As such, this provision effectively permits only
MA plans with no drug coverage to enroll individuals
throughout the year. MA plans that integrate prescription
drug coverage into their benefit packages would be kept under
the current law provision, that is, they would not be allowed
to enroll individuals throughout the year.
Title III--Medicare Program Integrity Efforts
Section 301. Offsetting adjustment in Medicare Advantage Stabilization
Fund
Current law
The Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 established a stabilization fund to
provide incentives for plans to enter into and to remain in
the Medicare Advantage regional program. Money in the fund is
available to the Secretary for expenditures from January 1,
2007 to December 31, 2013. Initially $10 billion is to be
provided to the stabilization fund and additional amounts are
to be added to the fund from a portion of any average per
capita monthly savings amounts. The secretary is responsible
for determining the amounts that may be given to MA plans
from this fund, based on statutory requirements. For example,
the national bonus payment will be available to an MA
organization that offers an MA regional plan in every MA
region in the year, but only if there was no national plan in
the previous year.
Explanation of provision
This provision would delay the initial availability of the
stabilization fund until January 1, 2012, and reduce the
amount of the fund to $3.5 billion.
Section 302. Extension and expansion of recovery audit contractor
program under the Medicare Integrity Program
(a) Use of recovery audit contractors
Current law
The Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (PL 108-73) authorized a 3-year
demonstration project using recovery audit contractors to
identify both under- and overpayments made to Part A and B
Medicare providers and recoup overpayments in the Medicare
program. The demonstration is being conducted as part of the
Medicare Integrity Program, created by section 1893 of the
Social Security Act, which enables the Secretary to enter
into contracts with entities to carry out a range of
activities designed to prevent health care fraud and abuse in
Parts A and B of the Medicare program. The Medicare Integrity
Program was established by the Health Insurance Portability
and Accountability Act of 1996 along with the Health Care
Fraud and Abuse Control Program. The program is financed via
the Federal Hospital Insurance Trust Fund.
Explanation of provision
Section 302 would allow the Centers for Medicare and
Medicaid Services (CMS) to continue using recovery audit
contractors to identify both under and overpayments made
under Medicare Parts A and B and recoup any overpayments made
to providers. To pay the contractors, the Secretary would be
required to use only those funds recovered by the
contractors. From these recoveries, the bill would require
the Secretary to pay the contractors in two ways: (1) on a
contingent basis for collecting overpayments; and (2) in
amounts that the Secretary may specify for identifying
underpayments. A portion of the recovered funds would be
available to the CMS program management account for
activities conducted under the recovery audit contractor
program. Any remaining recovered amounts--those recoveries
that are not paid to the contractors or applied to the CMS
program management account--would be used to reduce
expenditures under Medicare Parts A and B. It is also
expected that CMS will rectify any identified underpayments.
Each contract would be required to provide that audit and
recovery activities be conducted during the fiscal year
and retrospectively for not more than 4 fiscal years. The
Secretary would be allowed to waive Medicare statutory
provisions to pay for the services of the recovery audit
contractors.
By January 1, 2010, the Secretary would be required to
contract with enough recovery audit contractors to cover
Medicare activities in all states. When awarding contracts,
the Secretary would be required to contract only with
recovery audit contractors that have the staff with the
appropriate clinical knowledge of and experience with
Medicare payment rules and regulations, or recovery audit
contractors that will contract with another entity that has
the staff with the appropriate knowledge of and experience
with Medicare payment rules and regulations. The Secretary
shall give preference to entities with more than 3 years
direct management experience and a demonstrated proficiency
in audits with private insurers, health care providers,
health plans, state Medicaid programs or Medicare. Recovery
audit contractors cannot be fiscal intermediaries, carriers,
or Medicare Administrative Contractors, and the recovery of
overpayments by these contractors would not prohibit the
Secretary or the Attorney General from prosecuting
allegations of fraud and abuse arising from these
overpayments.
Finally, the Secretary would be required to submit a report
to Congress annually on the use of these recovery audit
contractors. Specifically the report would include
information on the performance of these contractors as it
relates to identifying over and underpayments and in
collecting overpayments. The report would also be required to
include an evaluation of the comparative performance of these
contractors and any Medicare savings that have accrued as a
result of their activities.
(b) Access to Coordination of Benefits Contractor database
Current law
The Coordination of Benefits (COB) Contractor consolidates
the activities that support the collection, management, and
reporting of other insurance coverage for Medicare
beneficiaries. The purposes of the COB program are to
identify the health benefits available to a Medicare
beneficiary and to coordinate the payment process to prevent
mistaken payment of Medicare benefits.
Explanation of provision
For the purpose of carrying out their audit and recovery
activities, the Secretary of
[[Page S11656]]
HHS would provide recovery audit contractors with access to
the database of the Coordination of Benefits Contractors of
the Centers for Medicare and Medicaid Services during the
current fiscal year and for a period of up to 4 fiscal years
prior to the current fiscal year.
(c) Conforming amendments to current demonstration project
Current law
Section 306 of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 requires that the Secretary's
demonstration project using recovery audit contractors last
for no longer than 3 years. After the completion of the
program, the Secretary shall submit to Congress a report on
the project and its impact on savings to the Medicare
program.
Explanation of provision
The provision would continue the use of recovery audit
contractors under the demonstration until all contracts could
be entered into. The provision would also eliminate the
requirement that the Secretary submit to Congress a report
not later than 6 months after the project's completion on the
impact of recovery audit contractors' activities on Medicare
savings.
Section 303. Funding for the Health Care Fraud and Abuse Control
Account
(a) Departments of Health and Human Services and Justice
Current law
The Health Insurance Portability and Accountability Act of
1996 (HIPAA, P.L. 104-91) established section 1128C of the
Social Security Act, which authorized the creation of a
national health care fraud and abuse control program headed
by the Secretary of HHS and the Attorney General. In section
1817(k) of the Social Security Act, HIPAA created an
expenditure account within the Medicare Federal Hospital
Insurance Trust Fund called the Health Care Fraud and Abuse
Control (HCFAC) Account. Within the HFCFAC account, the
legislation appropriated funds to HHS and DOJ at an amount of
$104 million in FY97 and for FY98 through FY03 at annual
increases of 15% above the preceding year. For each fiscal
year after 2003, the annual appropriation available to HHS
and DOJ was to be capped at the FY2003 level of $240.6
million. The legislation also established a separate funding
stream within the HCFAC account to support activities
undertaken by the FBI. Funding for the FBI was increased from
$47 million in FY97 to $114 million in FY03. The legislation
capped FBI funding at the FY03 level for FY03 and beyond.
Explanation of provision
Section 303 would extend appropriations for the Health Care
Fraud and Abuse Control Program through FY06 and beyond. For
FY98 through FY03, the annual appropriation to HHS and DOJ is
the limit for the preceding fiscal year increased by 15%. For
fiscal years 2007 through 2010, the annual appropriation
would be the limit for the preceding year plus the percentage
increase in the consumer price index for all urban consumers.
For each fiscal year beyond 2010, the legislation would
cap the appropriation at the FY10 level.
For the Office of the Inspector General of HHS, Section 303
would extend the annual appropriation of $160 million through
FY06. For FY07, the bill would increase the FY06
appropriation to OIG by the percentage increase in the
consumer price index. For fiscal years 2008, 2009, and 2010,
the annual appropriation would increase by the limit for the
preceding year plus the percentage increase in the consumer
price index for all urban consumers. For each fiscal year
after FY10, the legislation would cap the appropriation at
the FY10 level.
(b) Federal Bureau of Investigations
Current law
The Health Insurance Portability and Accountability Act of
1996 (HIPAA, P.L. 104-91) established section 1128C of the
Social Security Act, which authorized the creation of a
national health care fraud and abuse control program headed
by the Secretary of HHS and the Attorney General. In Section
1817(k) of the Social Security Act, HIPAA created an
expenditure account within the Medicare Federal Hospital
Insurance Trust Fund called the Health Care Fraud and Abuse
Control (HCFAC) Account. Within the HFCFAC account, the
legislation appropriated funds to HHS and DOJ at an amount of
$104 million in FY97 and for FY98 through FY03 at annual
increases of 15% above the preceding year. For each fiscal
year after 2003, the annual appropriation available to HHS
and DOJ was to be capped at the FY2003 level of $240.6
million. The legislation also established a separate funding
stream within the HCFAC account to support activities
undertaken by the FBI. Funding for the FBI was increased from
$47 million in FY97 to $114 million in FY03. The legislation
capped FBI funding at the FY03 level for FY03 and beyond.
Explanation of provision
Section 303 would extend the annual appropriation to the
Federal Bureau of Investigations (FBI). For fiscal years 2007
through 2010, the annual appropriation would be the limit for
the preceding year plus the percentage increase in the
consumer price index for all urban consumers. For each fiscal
year after 2010, the legislation would cap the appropriation
at the FY2010 level.
section 304. implementation funding
Current law
No current law.
Explanation of provision
For implementation of provisions and amendments made by
this title and titles I and II of this division, other than
the section requiring the Inspector General in the Department
of Health and Human Services to conduct a study of newer
events, the provision would require the Secretary of Health
and Human Services to transfer $45,000,000 to the CMS Program
Management Account for FY2007 and FY2008, from the Federal
Insurance Trust Fund, and the Federal Supplementary Medical
Insurance Trust, in appropriate proportions.
Title IV--Medicaid and Other Health Provisions
section 401. extension of transitional medical assistance (tma) and
abstinence education program
Current law
States are required to continue Medicaid benefits for
certain low-income families who would otherwise lose coverage
because of changes in their income. This continuation is
known as transitional medical assistance (TMA). Federal law
permanently requires four months of TMA for families who lose
Medicaid eligibility due to increased child or spousal
support collections, as well as those who lose eligibility
due to an increase in earned income or hours of employment.
Congress expanded work-related TMA under Section 1925 of the
Social Security Act in 1988, requiring states to provide TMA
to families who lose Medicaid for work-related reasons for at
least six, and up to 12, months. The sunset date for Section
1925 has been extended a number of times, most recently
through December 31, 2006 by the Deficit Reduction Act of
2005.
Under Section 510 of the Social Security Act, federal law
appropriated $50 million annually for each of the fiscal
years 1998-2003 for matching grants to states to provide
abstinence education and, at state option, mentoring,
counseling, and adult supervision to promote abstinence from
sexual activity, with a focus on groups that are most likely
to bear children out-of-wedlock. Funds must be requested by
states when they apply for Maternal and Child Health Services
(MCH) Block Grant funds and must be used exclusively for the
teaching of abstinence. States must match every $4 in federal
funds with $3 in state funds.
A state's allotment of abstinence education block grant
program funding is based on the proportion of low-income
children in the state as compared to the national total.
Funding for the abstinence education block grant has been
extended a number of times, most recently through December
31, 2006 by the Deficit Reduction Act of 2005.
Explanation of provision
The provision would extend TMA under Section 1925 of the
Social Security Act through June 30, 2007. It would also fund
the abstinence education block grant program through June 30,
2007 at the level provided through the third quarter of
FY2006.
section 402. grants for research on vaccine against valley fever
Current law
Under existing National Institutes of Health (NIH)
authority, the National Institute on Allergy and Infectious
Diseases has supported projects to study coccidioidomycosis,
known as Valley Fever. Grants have included projects to study
the organism that causes Valley Fever; to improve the ability
to evaluate vaccine candidates; to support the clinical
development of potential drug therapies; and to support
acquisition of equipment and facilities for research on the
disease, among others.
Explanation of provision
The Secretary is required to conduct research on the
development of a vaccine against coccidioidomycosis, known as
Valley Fever. Grants may not be made on or after October 1,
2012. This does not have any legal effect on payments for
grants for which amounts appropriated under this section were
obligated prior to October 1, 2012.
To carry out this section, $40 million is authorized for
fiscal years 2007-2012.
section 403. change in threshold for medicaid indirect hold harmless
provision of broad-based health care taxes
Current law
Under federal law and regulations, a state's ability to use
provider-specific taxes to fund their state share of Medicaid
expenditures is limited. If states establish provider
specific taxes, those taxes cannot generally exceed 25% of
the state (or non-federal) share of Medicaid expenditures and
the state cannot provide a guarantee to the providers that
the taxes will be returned to them. However, there is what is
referred to as a ``safe harbor.'' If the taxes returned to a
provider are less than 6% of the provider's revenues, the
prohibition on guaranteeing the return of tax funds is not
violated. Those taxes do not have to undergo the process,
defined in section 433.68 of Title 42 of the Code of Federal
Regulations, of determining if a guarantee exists. The
President's FY2006 budget proposes to phase the 6% ``safe
harbor'' for provider taxes down to 3% although no new
regulation has been issued on this subject to date.
Explanation of provision
Beginning on the date of enactment, the provider tax ``safe
harbor'' upper limit is codified at 6%. For the fiscal
periods beginning on or after January 1, 2008 and ending
before October 1, 2011, the ``safe harbor'' percentage will
be reduced from 6% to 5.5%.
[[Page S11657]]
After October 1, 2011, the provider tax ``safe harbor''
percentage will return to 6%.
section 404. dsh allotments for fiscal year 2007 for tennessee and
hawaii
(A) Tennessee
Current law
Tennessee operates its Medicaid program under a
comprehensive statewide waiver, the terms and conditions of
which have been negotiated by the state and CMS. Medicaid
demonstration waivers, authorized under Section 1115 of the
Social Security Act, allow states a great deal of flexibility
on how eligibility for Medicaid is determined, how Medicaid
services are provided, and what those services are comprised
of. States operating under a waiver are subject to a budget
neutrality requirement intended to hold program spending
under the waiver to estimates of amounts that would have been
spent in the absence of the waiver. Because Tennessee
receives its Medicaid funds under the provisions of the
waiver, it does not receive federal matching for Medicaid
payments to disproportionate share (DSH) hospitals nor do
they receive an allotment for DSH payments (state by state
allotments are calculated based on a formula in Medicaid law
and represent a federal cap on the amount that the federal
government will provide in DSH matching payments to any
state.) DSH payments, however, continue to be counted as a
component in Tennessee's budget neutrality calculation since,
in the period prior to the waiver approval, the state was
required to make DSH payments, and if the waiver had not been
granted, the requirement to make those payments would
continue to have applied.
Explanation of provision
The provision would establish a DSH allotment for the state
of Tennessee for fiscal year 2007 equal to the greater of the
amount that is reflected in the budget neutrality provision
for the TennCare demonstration year ending in 2006 and $280
million. Federal matching payments to the state for DSH
hospitals for fiscal year 2007 would, however, be limited to
one-third of the DSH allotment. Those amounts would be
considered TennCare project expenditures and would be
subtracted from TennCare demonstration payments for Essential
Access Hospital supplemental pool payments. The sum of the
DSH payments and the Essential Access Hospital supplemental
pool payments would be prohibited from exceeding the
allotment amount. The state would be permitted to submit a
state plan amendment describing the methodology to be used to
identify DSH hospitals and to make payments to such
hospitals. However, the Secretary may not approve the plan
amendment unless the methodology is consistent with the
requirements under Section 1923 of the Medicaid Act for
making payment adjustments for DSH hospitals.
(B) Hawaii
Current law
Like Tennessee, Hawaii operates its Medicaid program under
a statewide waiver, the terms and conditions of which have
been negotiated by the state and CMS. The state does not make
DSH payment under their waiver program and does not have a
DSH allotment in Medicaid law.
Explanation of provision
The provision would set a DSH allotment for Hawaii for
fiscal year 2007 at $10 million. The Secretary shall permit
Hawaii to submit an amendment to its State plan under this
title that describes the methodology to be used by the State
to identify and make payments to disproportionate share
hospitals, including children's hospitals and institutions
for mental diseases or other mental health facilities. The
Secretary may not approve such plan amendment unless the
methodology described in the amendment is consistent with the
requirements under this section for making payment
adjustments to disproportionate share hospitals.
section 405. certain medicaid dra technical corrections
(a) Technical corrections relating to state option for
alternative premiums and cost sharing (sections 6041
through 6043)
Current law
P.L. 109-171 allows states to impose premiums and cost-
sharing for any group of individuals for any type of service
(except prescribed drugs which are treated separately),
through Medicaid state plan amendments (rather than waivers),
subject to specific restrictions. Preferred drugs are defined
as those that are the least (or less) costly effective
prescription drugs within a class of drugs (as defined by the
state). Premium and cost-sharing rules for workers with
disabilities were not changed in P.L. 109-171.
Individuals in families with income below 100% of the
federal poverty line (FPL). Premiums and service-related
cost-sharing imposed under this option are allowed to vary
among classes or groups of individuals, or types of service.
Explicit rules are provided by income level for those with
income between 100-150% FPL and for those with income over
150% FPL.
States are allowed to condition the provision of medical
assistance on the payment of premiums, and to terminate
Medicaid eligibility on the basis of failure to pay a premium
if that failure continues for at least 60 days. States may
apply this provision to some or all groups of beneficiaries,
and may waive premium payments in cases where such payments
would be an undue hardship. In addition, the provision allows
states to permit providers participating in Medicaid to
require a Medicaid beneficiary to pay authorized cost-sharing
as a condition of receiving care or services. Providers may
be allowed to reduce or waive cost-sharing amounts on a case-
by-case basis.
For the purposes of cost-sharing, two income-related groups
are identified: (1) individuals in families with income
between 100 and 150% FPL, and (2) individuals in families
with income over 150% FPL. For both groups, the total
aggregate amount of all cost-sharing (including special cost
sharing rules for prescribed drugs and emergency room
copayments for non-emergency care) cannot exceed 5% of family
income as applied on a quarterly or monthly basis as
specified by the state.
Treatment of non-preferred drug cost-sharing. Special cost-
sharing for prescribed drugs is subject to the general 5%
aggregate cap on cost-sharing for individuals with income
between 100-150% FPL and for individuals with income over
150% FPL who are not otherwise exempt from service-related
cost-sharing.
Treatment of non-emergency cost-sharing. Individuals exempt
from premiums or service-related cost-sharing under other
provisions of P.L. 109-171 may be subject to nominal
copayments for non-emergency services in an ER, only when no
cost-sharing is imposed for care in hospital outpatient
departments or by other alternative providers in the area
served by the hospital ER. For non-exempt populations with
income between 100-150% FPL, cost-sharing for non-emergency
services in an ER cannot exceed twice the nominal amounts.
For non-exempt populations with income exceeding 150% FPL, no
cost-sharing limit is specified for non-emergency care in an
ER. Aggregate caps on cost-sharing (described above) still
apply.
Definition of non-emergency services. The term ``non-
emergency services'' means any care or services furnished in
an emergency department of a hospital that the physician
determines do not constitute an appropriate medical screening
examination or stabilizing examination and treatment required
to be provided by the hospital under Medicare law (Section
1867 of the Social Security Act).
Exemption from cost-sharing for newly eligible children
with disabilities. Section 6062 of P.L. 109-171 created a new
optional Medicaid eligibility group for children with
disabilities under age 19 who meet the severity of disability
required under the Supplemental Security Income program (SSI)
without regard to any income or asset eligibility
requirements applicable under SSI for children, and whose
family income does not exceed 300% FPL. (States can exceed
300% FPL, without federal matching funds for such coverage.)
Special premium and cost-sharing rules apply to this new
group of eligibles.
Explanation of provision
The definition of preferred drugs would be amended to
include those that are the most (or more) cost effective
prescription drugs within a class of drugs (as defined by
the state). In addition to separate cost-sharing
provisions for prescribed drugs, the amendment would
clarify that separate cost-sharing provisions also apply
to non-emergency services provided in an emergency room.
Individuals in families with income below 100% of the
federal poverty line (FPL). The provision would exempt from
the general cost-sharing rules in new Section 1916A (a) all
individuals in families with income below 100% of the federal
poverty line (FPL). However, Section 1916 of Title XIX
(nominal cost-sharing provisions) would still apply to this
income group, as would the comparability rule regarding
amount, duration and scope of available benefits (Section
1902(a)(10)(B)). States would still have the option to impose
the special cost-sharing rules for prescribed drugs and
nonemergency care provided in an emergency room to
individuals in families with income below 100% FPL.
The provision would exempt individuals in families with
income below 100% FPL from the provisions defining
enforceability of premiums and other cost-sharing.
Protections regarding payment of premiums and cost-sharing in
Section 1916(c)(3) and Section 1916(e) would continue to
apply to this income group.
The provision would apply the total aggregate cap of 5% of
family income to individuals in families with income below
100% FPL for applicable cost-sharing with respect to nominal
amounts (as defined in Section 1916), and prescribed drugs
and emergency room copayments for non-emergency care (as
defined in new Sections 1916A(c) and 1916A(e)).
Treatment of non-preferred drug cost-sharing. The
definition of preferred drugs would be amended to include
those that are the most (or more) cost effective prescription
drugs within a class of drugs (as defined by the state). In
addition to separate cost-sharing provisions for prescribed
drugs, the provision would clarify that separate cost-sharing
provisions also apply to non-emergency services provided in
an emergency room. The provision would clarify that no cost-
sharing for preferred drugs can be imposed on individuals
exempt from service-related cost-sharing under the general
cost-sharing provisions (identified in new Section 1916A(a)).
It would also clarify that no more than nominal cost-sharing
amounts may be imposed for non-preferred drugs on individuals
exempt from services-related cost-sharing under the general
cost-sharing provisions.
Treatment of non-emergency cost-sharing. The provision
would clarify that for non-exempt persons with income between
100-150%
[[Page S11658]]
FPL, cost-sharing for non-emergency care in an ER may not
exceed twice the applicable nominal amount (up to the 5%
aggregate cap). For persons with income below 100% FPL or who
are exempt from service-related cost-sharing, cost-sharing
for non-emergency care in an ER may not exceed the applicable
nominal amount when no cost-sharing is imposed by the
outpatient department or alternative providers. The 5%
aggregate cap on all service-related costsharing for all
income groups remains in effect.
Definition of non-emergency services. The provision would
strike the phrase ``the physician determines'' from the
definition of non-emergency services as provided in P.L. 109-
171.
Exemption from cost-sharing for newly eligible children
with disabilities. The provision would exempt this new
optional eligibility group for children with disabilities
established under P.L. 109-171 from the premium and service-
related cost-sharing rules under new Section 1916A.
Correction of IV-B References. Among the groups explicitly
exempted from the general cost-sharing provisions for
premiums and cost-sharing, the provision would change
references to Title IV-B to mean child welfare services made
available under Title IV-B on the basis of being a child in
foster care.
Effective Date. The provision specifies that all changes
made are effective as if included in the affected sections
and subsections of P.L. 109-171.
(b) Clarifying treatment of certain annuities (section
6012)
Current law
Under Section 6012(b) of P.L. 109-171, the purchase of an
annuity is treated as a disposal of an asset for less than
fair market value unless certain criteria are met. One of
these criteria is that the state be named as the remainder
beneficiary in the first position for at least the total
amount of Medicaid expenditures paid on behalf of the
annuitant or be named in the second position after the
community spouse or minor or disabled child and such spouse
or a representative of such child does not dispose of any
such remainder for less than fair market value.
Explanation of provision
The provision would strike the term ``annuitant'' and
replace it with ``institutionalized individual.'' This change
would become effective as if it had been included in DRA
2005, enacted on February 8, 2006.
(c) Additional miscellaneous technical corrections
(1) Documentation (section 6036)
Current law
Under Section 6036 of P.L. 109-171, states are prohibited
from receiving federal Medicaid reimbursement for an
individual who has not provided satisfactory documentary
evidence of citizenship or nationality. Documents that
provide satisfactory evidence are described in the law, as
are exceptions to the documentation requirement.
Section 6036(a)(2) of the law specifies that the
documentation requirements do not apply to an alien who is
eligible for Medicaid: and is entitled to or enrolled for
Medicare benefits; on the basis of receiving Supplemental
Security Income (SSI) benefits; or on such other basis as the
Secretary may specify that satisfactory documentary evidence
had been previously presented.
The provision applies to initial determinations and to
redeterminations of eligibility for Medicaid made on or after
July 1, 2006.
Explanation of provision
The provision would specify that the documentation
requirements do not apply to an individual declaring to be a
citizen or national of the United States who is eligible for
Medicaid: and is entitled to or enrolled for Medicare
benefits; and is receiving (1) Social Security benefits on
the basis of a disability or (2) SSI benefits; and with
respect to whom (1) child welfare services are made available
under Title IV-B of the Social Security Act or (2) adoption
or foster care assistance is made available under Title IV-E;
or on such basis as the Secretary may specify that
satisfactory documentary evidence has been previously
presented.
The provision would also make reference corrections. These
changes would be effective as if included in the Deficit
Reduction Act of 2005.
In addition, effective 6 months after enactment, the
provision would (1) require states to have procedures in
effect for verifying the citizenship or immigration status of
children in foster care under the responsibility of the state
under Title IV-E or IV-B of the Social Security Act and (2)
specify that in reviews of state programs under IV-E and IV-
B, the requirements subject to review shall include
determining whether the state program is in conformity with
the requirement to verify citizenship or immigration status.
(2) Miscellaneous technical corrections
Current law
Section 5114(a)(2). This P.L. 109-171 provision modified
the first sentence of Section 1842(b)(6)(F) of the Social
Security Act to add a new paragraph H to 1842(b)(6) so that a
federally qualified health center (FQHC) would be paid
directly for FQHC services provided by a health care
professional under contract with that FQHC.
Section 6003(b)(2). This P.L. 109-171 provision modified
Section 1927 of the Social Security Act by referencing
subsection (k) relating to Section 505(c) drugs.
Section 6031(b), 6032(b), and 6035(c). These sections
referenced Section 6035(e) of P.L. 109-171, which does not
exist, to provide exceptions to effective dates.
Section 6034(b). Section 6034 of P.L. 109-171 establishes
the Medicaid Integrity Program. It references modifications
made to the Social Security Act by Section 6033(a).
Section 6036(b). Section 6036 of P.L. 109-171 deals with
improved enforcement of documentation requirements. Section
6036(b) references Section 1903(z) of the Social Security
Act. This section does not exist.
Section 6015(a)(1). Section 6015 of P.L. 109-171 pertains
to continuing care retirement community admissions contracts.
It makes reference to clause (v) of Section
1919(c)(5)(A)(i)(II) of the Social Security Act.
Explanation of provision
Section 5114(a)(2). Instead of modifying Section
1842(b)(6)(F) to add paragraph H, the amendment would modify
Section 1842(b)(6) of the Social Security Act.
Section 6003(b)(2). Instead of referencing subsection (k)
of Section 1927 of the Social Security Act, the amendment
would reference subsection (k)(1).
Section 6031(b), 6032(b), and 6035(c). Instead of
referencing Section 6035(e), the amendment would reference
the effective date exception in Section 6034(e) of P.L. 109-
171.
Section 6034(b). Instead of referencing modifications made
by Section 6033(a) of P.L. 109-171, the amendment would
reference Section 6032(a).
Section 6036(b). Instead of referencing Section 1903(z) of
the Social Security Act, the amendment would reference
Section 1903(x).
Section 6015(a)(1). Instead of referencing clause (v) of
Section 1919(c)(5)(A)(i)(II) of the Social Security Act, the
amendment would reference subparagraph (B)(v).
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